Prevention of esophageal lesions during atrial fibrillation catheter ablation using esophageal temperature monitoring: A systematic review and meta-analysis

INTRODUCTION

The use of esophageal temperature monitoring (ETM) for the prevention of esophageal injury during atrial fibrillation (AF) ablation is often advocated. However, evidence supporting its use is scarce and controversial. We therefore aimed to review the evidence assessing the efficacy of ETM for the prevention of esophageal injury.

METHODS

We performed a meta-analysis and systematic review of the available literature from inception to December 31, 2022. All studies comparing the use of ETM, versus no ETM, during radiofrequency (RF) AF ablation and which reported the incidence of endoscopically detected esophageal lesions (EDELs) were included.

RESULTS

Eleven studies with a total of 1112 patients undergoing RF AF ablation were identified. Of those patients, 627 were assigned to ETM (56%). The overall incidence of EDELs was 9.8%. The use of ETM during AF ablation was associated with a non significant increase in the incidence of EDELs (12.3% with ETM, vs. 6.6 % without ETM, odds ratio, 1.44, 95%CI, 0.49, 4.22, p = .51, I2 = 72%). The use of ETM was associated with a significant increase in the energy delivered specifically on the posterior wall compared to patients without ETM (mean power difference: 5.13 Watts, 95% CI, 1.52, 8.74, p = .005).

CONCLUSIONS

The use of ETM does not reduce the incidence of EDELs during RF AF ablation. The higher energy delivered on the posterior wall is likely attributable to a false sense of safety that may explain the lack of benefit of ETM. Further randomized controlled trials are needed to provide conclusive results.

The influence of cardiac arrhythmias on the detection of heartbeats in the photoplethysmogram: benchmarking open-source algorithms

Objective.Cardiac arrhythmias are a leading cause of mortality worldwide. Wearable devices based on photoplethysmography give the opportunity to screen large populations, hence allowing for an earlier detection of pathological rhythms that might reduce the risks of complications and medical costs. While most of beat detection algorithms have been evaluated on normal sinus rhythm or atrial fibrillation recordings, the performance of these algorithms in patients with other cardiac arrhythmias, such as ventricular tachycardia or bigeminy, remain unknown to date.Approach. ThePPG-beatsopen-source framework, developed by Charlton and colleagues, evaluates the performance of the beat detectors namedQPPG,MSPTDandABDamong others. We applied thePPG-beatsframework on two newly acquired datasets, one containing seven different types of cardiac arrhythmia in hospital settings, and another dataset including two cardiac arrhythmias in ambulatory settings.Main Results. In a clinical setting, theQPPGbeat detector performed best on atrial fibrillation (with a medianF1score of 94.4%), atrial flutter (95.2%), atrial tachycardia (87.0%), sinus rhythm (97.7%), ventricular tachycardia (83.9%) and was ranked 2nd for bigeminy (75.7%) behindABDdetector (76.1%). In an ambulatory setting, theMSPTDbeat detector performed best on normal sinus rhythm (94.6%), and theQPPGdetector on atrial fibrillation (91.6%) and bigeminy (80.0%).Significance. Overall, the PPG beat detectorsQPPG,MSPTDandABDconsistently achieved higher performances than other detectors. However, the detection of beats from wrist-PPG signals is compromised in presence of bigeminy or ventricular tachycardia.

[Cardiology: what's new in 2023]

The year 2023 has been extremely rich in new publications in the various subfields of cardiology. Furthermore, the European Society of Cardiology (ESC) has issued revised guidelines focused on the management of acute coronary syndrome (ACS) and endocarditis, as well as an update on the recommendations for the management of heart failure and cardiovascular prevention. The most significant updates according to the Cardiology Department of CHUV are summarized in this review article.

Multi-catheter cryotherapy for the treatment of resistant accessory pathways

OBJECTIVE

To investigate the utility of simultaneous multi-catheter cryotherapy for the treatment of APs that were previously resistant to standard radiofrequency (RF) catheter ablation.

BACKGROUND

Catheter ablation is established in the treatment of accessory pathways (AP), with high rates of permanent procedural success with a single attempt. However, there are still instances of acute procedural failure and AP recurrences with standard RF and cryotherapy methods.

METHODS

Seven consecutive cases of pre-excitation syndromes with prior failed RF catheter ablation had the novel treatment. Cryotherapy was delivered using two 8 mm tip focal cryoablation catheters (Freezor® Max, Medtronic, Minneapolis, Minnesota, USA).

RESULTS

Accessory pathway localisation was septal in 5 cases, left posterolateral in 1, right lateral in 1. In all cases, ablation of the AP was acutely successful with no procedural complications. Median procedure and fluoroscopy durations were 199 and 35 min, sequentially. Median Procedure duration fell significantly in the second half of series (174 min) compared to the first half (233 min, P = 0.05). One patient had evidence of a recurring AP conduction with pre-excitation at 5-week follow up. After a median follow up of 66.8+-6.5 months, 6 out of 7 patients remained asymptomatic and free of pre-excitation.

CONCLUSION

Simultaneous multi-catheter cryotherapy is feasible, safe and can provide definitive cure of accessory pathways that were previously resistant to standard radiofrequency ablation. Further study is required in the assessment of this novel form of advanced cryotherapy to treat complex and resistant arrhythmias.

Recurrences of ventricular tachycardia after stereotactic arrhythmia radioablation arise outside the treated volume: analysis of the Swiss cohort

AIMS

Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of therapy-refractory ventricular tachycardia (VT). VT recurrences have been reported after STAR but the mechanisms remain largely unknown. We analysed recurrences in our patients after STAR.

METHODS AND RESULTS

From 09.2017 to 01.2020, 20 patients (68 ± 8 y, LVEF 37 ± 15%) suffering from refractory VT were enrolled, 16/20 with a history of at least one electrical storm. Before STAR, an invasive electroanatomical mapping (Carto3) of the VT substrate was performed. A mean dose of 23 ± 2 Gy was delivered to the planning target volume (PTV). The median ablation volume was 26 mL (range 14-115) and involved the interventricular septum in 75% of patients. During the first 6 months after STAR, VT burden decreased by 92% (median value, from 108 to 10 VT/semester). After a median follow-up of 25 months, 12/20 (60%) developed a recurrence and underwent a redo ablation. VT recurrence was located in the proximity of the treated substrate in nine cases, remote from the PTV in three cases and involved a larger substrate over ≥3 LV segments in two cases. No recurrences occurred inside the PTV. Voltage measurements showed a significant decrease in both bipolar and unipolar signal amplitude after STAR.

CONCLUSION

STAR is a new tool available for the treatment of VT, allowing for a significant reduction of VT burden. VT recurrences are common during follow-up, but no recurrences were observed inside the PTV. Local efficacy was supported by a significant decrease in both bipolar and unipolar signal amplitude.

Conduction System Pacing versus Conventional Biventricular Pacing for Cardiac Resynchronization Therapy: Where Are We Heading?

Over the last few years, pacing of the conduction system (CSP) has emerged as the new standard pacing modality for bradycardia indications, allowing a more physiological ventricular activation compared to conventional right ventricular pacing. CSP has also emerged as an alternative modality to conventional biventricular pacing for the delivery of cardiac resynchronization therapy (CRT) in heart failure patients. However, if the initial clinical data seem to support this new physiological-based approach to CRT, the lack of large randomized studies confirming these preliminary results prevents CSP from being used routinely in clinical practice. Furthermore, concerns are still present regarding the long-term performance of pacing leads when employed for CSP, as well as their extractability. In this review article, we provide the state-of-the-art of CSP as an alternative to biventricular pacing for CRT delivery in heart failure patients. In particular, we describe the physiological concepts supporting this approach and we discuss the future perspectives of CSP in this context according to the implant techniques (His bundle pacing and left bundle branch area pacing) and the clinical data published so far.

Transvenous Lead Extraction during Cardiac Implantable Device Upgrade: Results from the Multicenter Swiss Lead Extraction Registry

BACKGROUND

Device patients may require upgrade interventions from simpler to more complex cardiac implantable electronic devices. Prior to upgrading interventions, clinicians need to balance the risks and benefits of transvenous lead extraction (TLE), additional lead implantation or lead abandonment. However, evidence on procedural outcomes of TLE at the time of device upgrade is scarce.

METHODS

This is a post hoc analysis of the investigator-initiated multicenter Swiss TLE registry. The objectives were to assess patient and procedural factors influencing TLE outcomes at the time of device upgrades.

RESULTS

941 patients were included, whereof 83 (8.8%) had TLE due to a device upgrade. Rotational mechanical sheaths were more often used in upgraded patients (59% vs. 42.7%, p = 0.015) and total median procedure time was longer in these patients (160 min vs. 105 min, p < 0.001). Clinical success rates of upgraded patients compared to those who received TLE due to other reasons were not different (97.6% vs. 93.0%, p = 0.569). Moreover, multivariable analysis showed that upgrade procedures were not associated with a greater risk for complications (HR 0.48, 95% confidence interval 0.14-1.57, p = 0.224; intraprocedural complication rate of upgraded patients 7.2% vs. 5.5%). Intraprocedural complications of upgraded patients were mostly associated with the implantation and not the extraction procedure (67% vs. 33% of complications).

CONCLUSIONS

TLE during device upgrade is effective and does not attribute a disproportionate risk to the upgrade procedure.

Case report: First-in-human combined low-dose whole-heart irradiation and high-dose stereotactic arrhythmia radioablation for immunosuppressive refractory cardiac sarcoidosis and ventricular tachycardia

Background

Cardiac sarcoidosis is associated with heart failure, conduction abnormalities, and life-threatening arrhythmias including ventricular tachycardia (VT). Radiotherapy has been suggested as a treatment for extra-cardiac sarcoidosis in patients refractory to immunomodulatory treatment.

Methods

The effectiveness and safety of low-dose whole-heart radiotherapy for therapy refractory cardiac sarcoidosis were evaluated in a pre- and post-intervention case report comparing the 54 months before and after treatment. Immunomodulatory low-dose whole-heart irradiation as sarcoidosis treatment consisted of a 2 × 2 Gy scheme. Additionally, high-dose single-fraction stereotactic arrhythmia radioablation of 1 × 20 Gy was applied to the pro-arrhythmic region to manage the ventricular tachycardia episodes. Cardiac sarcoidosis disease activity was measured by hypermetabolic areas on repeated fluorodeoxyglucose ([18F]FDG)-PET/computed tomography (CT) scans and by evaluating changes in ventricular tachycardia episodes before and after treatment.

Results

One patient with therapy refractory progressive cardiac sarcoidosis and recurrent ventricular tachycardia was treated. The cardiac sarcoidosis disease activity showed a durable regression of inflammatory disease activity from 3 months onwards. The [18F]FDG-PET/CT scan at 54 months did not show any signs of active cardiac sarcoidosis, and a state of remission was achieved. The number of sustained VT episodes was reduced by 95%. We observed that the development of moderate aortic valve regurgitation was likely irradiation-related. No other irradiation-related adverse events occurred, and the left ventricular ejection fraction remained stable.

Conclusion

We report here for the first time on the beneficial and lasting effects of combined immunomodulatory low-dose whole-heart radiotherapy and high-dose stereotactic arrhythmia radioablation in a patient with therapy refractory cardiac sarcoidosis and recurrent VT.

Effects of Stereotactic Arrhythmia Radioablation on left ventricular ejection fraction and valve function over time

Twenty patients (80% male) were included, 15 (75%) with a non-ischemic cardiomyopathy. The radiotherapy dose was 20Gy (20;25) prescribed to a planning target volume (PTV) of 25cc (18;39) resulting in a median whole-heart dose of 6.1Gy. The follow-up duration before and after STAR was 2.1 (0.6;4.5) and 1.7 (0.9;3.9) years respectively. The number of echocardiograms was 5 (3;7) before and 4 (2;7) after STAR.

[Cardiology: what's new in 2022]

The year of 2022 was marked by many novelties in the fields of interventional cardiology, heart failure, electrophysiology, cardiac imaging, and congenital heart disease. These advances will certainly change our daily practice, on top of improving the diagnosis and treatment of many heart conditions. In addition, the European Society of Cardiology has updated its guidelines on pulmonary hypertension, ventricular arrhythmias and sudden death, cardiovascular assessment of patients undergoing non-cardiac surgery. The members of the Cardiology division of Lausanne University Hospital (CHUV) here present the publications which they considered to be the most important of the past year.

Recurrences after stereotactic arrhythmia radioablation for refractory ventricular tachycardia

Introduction

Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of ventricular tachycardia (VT) refractory to antiarrhythmic drugs (AADs) and catheter ablation (CA). VT recurrences were recently reported after STAR but the mechanisms remain poorly known.

Purpose

We analyzed VT recurrences after STAR for refractory VT in order to assess the characteristics and delivered dose at sites of VT relapse.

Methods

From 09.2017 to 01.2020, 12 consecutive patients (pts) (66±8y, LVEF 40±14%) suffering from refractory VT were enrolled. The underlying cardiopathy was ischemic in 3, inflammatory in 3 and idiopathic in 6 pts. Nine (75%) out of 12 pts had a history of at least 1 electrical storm. Before STAR, an invasive electro-anatomical mapping (Carto3) of the VT substrate (VT-sub) was performed. A mean dose of 22±2Gy was delivered to the VT-sub using the Cyberknife® system.

Results

The ablation volume was 24±7cc and involved the basal interventricular septum (IVS) in 10 (83%) pts. During the first 6 months after STAR, VT burden decreased by 93% (mean value, from 640 to 46 VT/semester). After a median follow-up of 32±11 months, 10/12 (83%) developed ≥1 recurrence as a sustained VT and underwent a redo CA. Two (17%) pts presented 2 distinct VT recurrences from clearly different areas. VT recurrence was located at the border zone (BZ) of the treated VT-sub in 6 (50%) cases, involved both the BZ and a larger substrate in 2 (17%) cases, and occurred remote from the VT-sub in 4 (33%) cases (see Table 1). The dose delivered at sites of VT recurrence was 8.4±8.6 Gy with a large heterogeneity ranging from 0.11 to 28.37 Gy, for some pts due to dose constraints near critical structures (coronary arteries). Voltage mapping showed a small but significant reduction in both unipolar and bipolar EGM voltage in the irradiated area after STAR (before vs after, Bipolar: 1.8±1.2 vs 1.1±1.2 mV and Unipolar: 4.4±2.0 vs 3.4±2.3 mV, p=0.02 and 0.01 respectively). Importantly no pts developed a high-grade AV block after STAR despite IVS irradiation.

Conclusion

STAR appears to be an efficient tool for the management of refractory VT, leading to a strong VT burden reduction and no new high-grade AV block. Recurrences were nevertheless common, often at the border zone of the irradiated volume.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): CHUV

Yield of the electrophysiological study in patients with new-onset left bundle branch block after transcathether aortic valve replacement: The PR interval matters

Background

Studies suggest that performing an electrophysiological study (EPS) may be useful to identify patients with new-onset left bundle branch block (LBBB) post-TAVR at risk of atrioventricular block. However, tools to optimize the yield of such strategy are needed. We therefore aimed to investigate whether 12-lead ECG changes post-TAVR may help identify patients with abnormal EPS findings.

Materials and methods

Consecutive patients with new-onset LBBB post-TAVR who underwent EPS were included. PR and QRS intervals were measured on 12-lead ECG pre-TAVR and during EPS. Abnormal EPS was defined as an HV interval > 55 ms.

Results

Among 61 patients, 28 (46%) had an HV interval > 55 ms after TAVR. Post-TAVR PR interval and ΔPR (PR-post–pre-TAVR) were significantly longer in patients with prolonged HV (PR: 188 ± 38 vs. 228 ± 34 ms, p < 0.001, ΔPR: 10 ± 30 vs. 34 ± 23 ms, p = 0.001), while no difference was found in QRS duration. PR and ΔPR intervals both effectively discriminated patients with HV > 55 ms (AUC = 0.804 and 0.769, respectively; p < 0.001). A PR > 200 ms identified patients with abnormal EPS results with a sensitivity of 89% and a negative predictive value (NPV) of 88%. ΔPR ≥ 20 ms alone provided a somewhat lower sensitivity (64%) but combining both criteria (i.e., PR > 200 ms or ΔPR ≥ 20 ms) identified almost every patients with abnormal HV (sensitivity = 96%, NPV = 95%). Selecting EPS candidate based on both criteria would avoid 1/3 of exams.

Conclusion

PR interval assessment may be useful to select patients with new-onset LBBB after TAVR who may benefit most from an EPS. In patients with PR ≤ 200 ms and ΔPR < 20 ms the likelihood of abnormal EPS is very low independently of QRS changes.

Refractory ventricular tachycardia treated by a second session of stereotactic arrhythmia radioablation

•

Arrhythmia radioablation (STAR) is effective in refractory ventricular tachycardia.

•

We report the first cases of successful re-irradiation of arrhythmogenic substrate.

•

No radiation toxicity was observed after the second STAR.

•

Caution is advised as data on early and late toxicities remain scarce.

Purpose

Stereotactic arrhythmia radioablation (STAR) is an effective treatment for refractory ventricular tachycardia (VT), but recurrences after STAR were recently published. Herein, we report two cases of successful re-irradiation of the arrhythmogenic substrate.

Cases

We present two cases of re-irradiation after recurrence of a previously treated VT with radioablation at a dose of 20 Gy. The VT exit was localized on the border zone of the irradiated volume, which responded positively to re-irradiation at follow-up.

Conclusion

These two cases show the technical feasibility of re-irradiation to control recurrent VT after a first STAR.

[Epicardial adipose tissue and atrial fibrillation]

Atrial fibrillation (AF) is the most common arrhythmia encountered in adults; it is associated with a significant morbidity and mortality. Obesity is a risk factor contributing to AF occurrence. Recently, interest has focused on epicardial adipose tissue (EAT), defined as a fatty deposit located between the epicardium and the visceral pericardium. Its characteristics are distinct from classic adipose deposits: it infiltrates the epicardial myocardium and secretes cytokines, which modulate cardiomyocyte electrophysiology and cardiac remodeling. Different studies show that EAT can be an independent risk factor for AF and that EAT thickness, as measured by CT or MRI, could predict the presence, severity and recurrence of AF.

Programmed ventricular stimulation for risk stratification in patients with myocardial scarring and an ejection fraction above or equal to 40%

Funding Acknowledgements

Type of funding sources: None.

Background

Sudden cardiac death (SCD) is one of the leading causes of death, particularly among patients with myocardial scars. Implantable cardioverter defibrillators (ICD) are recommended in patients with a left ventricular ejection fraction (LVEF) ≤ 35%. Another recognised indication is the induction of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) during programmed ventricular stimulation (PVS) in post-myocardial infarction patients with non-sustained VT and a LVEF between 35% and 40%. However, no recommendation exists to guide the use of prophylactic ICD implantation in patients with less altered LVEF, even though they represent the majority of SCDs.

Purpose

We aimed to evaluate the prognostic value of PVS in patients with myocardial scars and a relatively preserved LVEF (≥ 40%).

Methods

Patients with evidence of a chronic myocardial scar and a LVEF ≥ 40%, who underwent PVS at two hospital centers were considered for inclusion. Ischemic and non-ischemic myocardial scars were included. The primary endpoint was the occurrence of a Major Arrhythmic Event (MAE), namely SCD, clinical VT/ventricular fibrillation, or appropriate ICD therapy.

Results

134 patients were included (mean age 62.4 ± 12.5 years, LVEF 54.7 ± 8.6 %). Indication for PVS was mostly non-sustained VT and/or syncope (84%). Post-myocardial infarction patients represented about half of the cases (53%). Inducibility during PVS was observed in 17 patients (13%). There was a nonsignificant trend towards higher inducibility rates in ischemic versus nonischemic scars (17% and 8%, respectively; p-value = 0.1). Of these patients, 15 received an ICD (88%). Over a mean follow-up of 49 (±42) months, a MAE occurred in 7 patients (41.2%) with positive PVS, versus 4 patients (3.4%) with negative PVS. MAE-free survival at 10 years was 91% and 43% in PVS-negative and PVS-positive patients, respectively (p-value &lt; 0.001). One SCD occurred in a PVS-positive patient who denied prophylactic ICD implantation. Inducibility during PVS provided a 64% sensitivity and a 97% negative predictive value (PV) to predict the occurrence of MAE (specificity 92%, positive PV 41%).

Conclusion

PVS is a useful tool to discriminate patients with myocardial scars and LVEF ≥ 40% at increased arrhythmic risk. Effective utilisation of ICD may be anticipated in case of positive PVS, while non-inducible patients are at lower MAE risk.

Risk factors for gram-negative infection of cardiovascular implantable electronic devices: retrospective multicenter study - CarDINe study

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Dr. Fabbricatore is supported by a research grant from the CardioPaTh PhD Program

Background

Gram-negative bacteria (GNB) are unfrequently isolated from patients with cardiac implantable electronic device (CIED) infection. However, data about risk factors for GNB-CIED-infection and associated clinical outcome are missing.

Methods

Multicenter, retrospective case-control-control study. Adult patients undergoing CIED implantation from Jan 2015 to Dec 2019 were included and classified as case (C) if diagnosed of GNB-CIED-infection; control 1 (C1) if diagnosed with Gram positive bacteria (GPB)-CIED infection; and control 2 (C2) if no CIED-infection was diagnosed during the study period. Patients were matched by center and risk period (from CIED implantation to infection diagnosis ±1 month), with a minimum follow-up period after infection diagnosis of 180 days.

Results

Study cohort consisted of 134 patients (33 C, 53 C1 and 42 C2) from 11 centers. Overall, 99 (73.9%) were male, median age 73 (IQR 66-81) years. Cardiac diseases leading to CIED implantation were bradi-arrythmia (48%), hearth failure (23.5), and primary prevention (20.6%). There were not differences for demographic variables and Charlson Index between C, C1 and C2. Time from implantation to infection diagnosis was similar between C and C1 [274 (39-621) vs 220 (58-866) days, p=0.581]. Shariff score was lower in C compared with C1 [1(1-2) vs 2 (1-3); p&lt;0.001]. C reported more frequently than C1 a prior infection (not CIED related) (33% vs 16%, p=0.08). GN and GP causative agents of CIED-infection are depicted in Fig.1. No differences regarding CIED-infection type (pocket site, endocarditis) were observed between C and C1. Interestingly, PET-FDG was more frequently performed in C compared with C1 (41.2% vs 17%, p=0.013), with a trend toward higher yielding (83% vs. 50%, p=0.16). CIED extraction was performed in 79.4% and 92.5% (p=0.07) of C and C1, respectively. Length of stay was similar between groups [17 (7-39) vs23 (12-41) days, p=0.326]. 6-month survival was significantly lower in C compared with C1 and C2 at Kaplan Meier analysis (Fig.2).

Conclusions

GNB-CIED infection is associated with higher 6-month mortality than GPB- or no-CIED infections, prior GNB infection may favor subsequent GNB-CIED infection, the role of PET-FDG in diagnosing GNB-CIED infection seems to be key.

Recurrences after stereotactic arrhythmia radioablation for refractory ventricular tachycardia

Funding Acknowledgements

Type of funding sources: None.

Introduction

Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of ventricular tachycardia (VT) refractory to antiarrhythmic drugs and catheter ablation (CA). VT recurrences have been reported after STAR but the mechanisms remain poorly known. We analyzed recurrences in our patients (pts) after STAR for refractory VT.

Methods

From 09.2017 to 01.2020, 12 pts (66±8y, LVEF 40±14%) suffering from refractory VT were enrolled. The underlying cardiopathy was ischemic in 3, inflammatory in 3 and idiopathic in 6 pts. Nine out of 12 pts had a history of at least 1 electrical storm. Before STAR, an invasive electro-anatomical mapping of the VT substrate (VT-sub) was performed. A mean dose of 22±2Gy was delivered to the VT-sub using the Cyberknife system.

Results

The ablation volume was 24±7cc and involved the basal interventricular septum (IVS) in 10 pts. During the first 6 months after STAR, VT burden decreased by 95% (mean value, from 930 to 46 VT/semester). After a median follow-up of 14±10 months, 10/12 (83%) developed a recurrence as a sustained VT and underwent a redo CA. VT recurrence was located at the border zone (BZ) of the treated VT-sub in 6 cases, involved both the BZ and a larger substrate in 2 cases, and occurred remote from the VT-sub in 2 cases (see Table). The dose delivered at sites of VT recurrence was 9.9±8.6 Gy with a large heterogeneity ranging from 0.11 to 28.37 Gy, for some patients due to dose constraints near critical structures. Importantly no pts developed an AV block after STAR.

Conclusion

STAR appears to be an efficient tool for the management of IVS refractory VT, leading to a strong VT burden reduction and no AV block. Recurrences were nevertheless common, often at the border zone of the irradiated volume.

Patient Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: A comparison of two professions

BACKGROUND

With an increasing number of cardiac implantable electronic devices, there has been a paralleled increase in demand for transvenous lead extraction (TLE). Cardiac surgeons (CS) and cardiologists perform TLE; however, data comparing the two groups of operators is scarce.

OBJECTIVE

We compared the outcomes of TLE performed by cardiologists and CS from six European lead extraction units.

METHOD

Data was collected retrospectively of 2205 patients who had 3849 leads extracted (PROMET) between 2005-2018. Patient demographics and procedural outcomes were compared between the CS and cardiologist groups, using propensity score matching. A multivariate regression analysis was also performed for variables associated with 30-day mortality.

RESULTS

Cardiac surgeons performed the majority of extractions (59.8%), of leads with longer dwell times (90 [57-129 interquartile range (IQR)] vs 62 [31-102 IQR] months, CS vs cardiologists, p < 0.001) and with pre-dominantly non-infectious indications (57.4% vs 50.2%, CS vs cardiologists, p < 0.001). Cardiac surgeons achieved a higher complete success per lead than the cardiologists (98.1% vs 95.7%, respectively, p < 0.01), with a higher number of minor complications (5.51% vs 2.1%, p < 0.01) and similar number of major complications (0.47% vs 1.3%, p = 0.12). Thirty-day mortality was similarly low in the CS and cardiologist groups (1.76% vs 0.94%,p = 0.21). Unmatched data multivariate analysis revealed infection indication (OR 6.12 [1.9-20.3], p < 0.01), procedure duration (OR 1.01 [1.01-1.02], p < 0.01) and CS operator (OR 2.67, [1.12-6.37], p = 0.027) were associated with 30-day mortality.

CONCLUSION

Transvenous lead extraction by CS was performed with similar safety and higher efficacy compared to cardiologists in high and medium-volume lead extraction centres. This article is protected by copyright. All rights reserved.

New Insights in Central Venous Disorders. The Role of Transvenous Lead Extractions

Over the last decades, the implementation of new technology in cardiac pacemakers and defibrillators as well as the increasing life expectancy have been associated with a higher incidence of transvenous lead complications over time. Variable degrees of venous stenosis at the level of the subclavian vein, the innominate trunk and the superior vena cava are reported in up to 50% of implanted patients. Importantly, the number of implanted leads seems to be the main risk factor for such complications. Extraction of abandoned or dysfunctional leads is a potential solution to overcome venous stenosis in case of device upgrades requiring additional leads, but also, in addition to venous angioplasty and stenting, to reduce symptoms related to the venous stenosis itself, i.e., the superior vena cava syndrome. This review explores the role of transvenous lead extraction procedures as therapeutical option in case of central venous disorders related to transvenous cardiac leads. We also describe the different extraction techniques available and other clinical indications for lead extractions such as lead infections. Finally, we discuss the alternative therapeutic options for cardiac stimulation or defibrillation in case of chronic venous occlusions that preclude the implant of conventional transvenous cardiac devices.

[Cardiology]

Significant advances have been made in 2021 in the areas of interventional cardiology, heart failure, cardiac imaging, electrophysiology and congenital heart disease. In addition to improving the screening, diagnosis and management of many heart diseases, these advances will change our daily practice. Moreover, the European Society of Cardiology has updated its guidelines on heart failure, valve disease, cardiac pacing and cardiovascular disease prevention. As in previous years, members of the Cardiology division of Lausanne University Hospital (CHUV) came together to select and present to you the papers that they considered to be the most important of the past year.

Feasibility of adenosine stress cardiovascular magnetic resonance perfusion imaging in patients with MR-conditional transvenous permanent pacemakers and defibrillators

BACKGROUND

The use of stress perfusion-cardiovascular magnetic resonance (CMR) imaging remains limited in patients with implantable devices. The primary goal of the study was to assess the safety, image quality, and the diagnostic value of stress perfusion-CMR in patients with MR-conditional transvenous permanent pacemakers (PPM) or implantable cardioverter-defibrillators (ICD).

METHODS

Consecutive patients with a transvenous PPM or ICD referred for adenosine stress-CMR were enrolled in this single-center longitudinal study. The CMR protocol was performed using a 1.5 T system according to current guidelines while all devices were put in MR-mode. Quality of cine, late-gadolinium-enhancement (LGE), and stress perfusion sequences were assessed. An ischemia burden of ≥ 1.5 segments was considered significant. We assessed the safety, image quality and the occurrence of interference of the magnetic field with the implantable device. In case of ischemia, we also assessed the correlation with the presence of significant coronary lesions on coronary angiography.

RESULTS

Among 3743 perfusion-CMR examinations, 66 patients had implantable devices (1.7%). Image quality proved diagnostic in 98% of cases. No device damage or malfunction was reported immediately and at 1 year. Fifty patients were continuously paced during CMR. Heart rate and systolic blood pressure remained unchanged during adenosine stress, while diastolic blood pressure decreased (p = 0.007). Six patients (9%) had an ischemia-positive stress CMR and significant coronary stenoses were confirmed by coronary angiography in all cases.

CONCLUSION

Stress perfusion-CMR is safe, allows reliable ischemia detection, and provides good diagnostic value.

Feasibility and prognostic value of adenosine stress perfusion cardiovascular magnetic resonance in patient with implantable device

Funding Acknowledgements

Type of funding sources: None.

Background

stress CMR has a limited use in patients with implantable device, in order to the possible artefacts due to the metallic component and to the risk of adenosine interaction with cardiac pacing. The aim of the study was to assess the global feasibility and to assess the prognostic value of stress perfusion CMR in patients with implantable device.

Materials and Methods

we conducted a retrospective single-center longitudinal analysis of consecutive patients with an implantable device referred for stress CMR, performed using a 1.5 Tesla unit (Siemens Healthcare,MAGNETOM Aera, Erlangen-Germany). Protocol was adapted according to current guidelines. Cardiac follow-up [6 months to 7 years] was obtained by medical records of direct contact with patient’s cardiologist referral. 

Results

44 patients were enrolled. 34 patients needed a continuous pacing during adenosine stress, that was settled in DOO in 14 (32%) and in VOO in 20 (45%). Device integrity was not compromised by CMR and not competitive atrial or ventricular stimulation was observed during examination. Image quality was good in 95% cases. 26% cases had a perfusion deficit corresponding to a previous scar, while 12% of patients had a positive stress test. All of them needed continuous pacing during stress test and underwent to a coronary angiography who confirmed the coronary stenosis.  In patients without inducible ischemia 2 patients experienced a Non-ST-elevation Myocardial Infarction after 6 and 2 years while no other cardiac symptoms or cardiac hospitalisation was remarkable during follow up.

Conclusion

adenosine stress CMR in patient who are pacemaker dependent during scanner is feasible, with an overall good image quality, proving an excellent diagnostic and prognostic value in a long term follow up even. Adenosine administration is safe and no the magnetic field interference with the correct functioning of the device have been shown in short or long term follow-up.

Transvenous lead extraction: The influence of age on patient outcomes in the PROMET study cohort

BACKGROUND

Cardiac implantable electronic device (CIED) therapy contributes to an improvement in morbidity and mortality across all patient demographics. Patient age is a recognized risk factor for unfavorable outcomes in invasive procedures. This is the largest series of non-laser transvenous lead extraction (TLE) evaluating the association between patient age and procedure outcomes.

METHODS

Data of 2205 (3849 leads) patients was collected retrospectively from six European TLE centers between January 2005-December 2018 in the PROMET study. Of these, 153 patients with 319 leads were excluded for incomplete data. A comparison of outcomes was performed between the age groups young [< 50 years], young intermediate [50-69 years], older intermediate [70-79 years], and octogenarian [≥80 years].

RESULTS

Infection was most common indication for TLE in the octogenarian cohort, less common in the younger population (60.1% vs. 33.2%, respectively, p < .01). High-voltage leads were extracted most frequently from young patients, less frequently from octogenarians (31.6% vs. 10%, p < .001), while the opposite was evident for pacemaker leads (p < .001). Rotational sheath use was equally prevalent across all patient groups (p = .79). Minor and major complications across all the age groups were statistically similar, as was procedural success; the 30-day mortality was most significant in the octogenarian and least in the young patients (4.9% vs. 0.4%, p = .005). Propensity matching multivariate analysis found systemic infection, lead dwell time, and patient age (p = .013, OR 1.064 [1.013-1.116]) increased risk of 30-day mortality.

CONCLUSION

TLE is safe and effective across all age groups. 30-day mortality risk is significantly higher in the older patients.

Results of the Patient-Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: a multicentre retrospective study on advanced mechanical lead extraction techniques

AIMS

Several large studies have documented the outcome of transvenous lead extraction (TLE), focusing on laser and mechanical methods. To date there has been no large series addressing the results obtained with rotational lead extraction tools. This retrospective multicentre study was designed to investigate the outcomes of mechanical and rotational techniques.

METHODS AND RESULTS

Data were collected on a total of 2205 patients (age 66.0 ± 15.7 years) with 3849 leads targeted for extraction in six European lead extraction centres. The commonest indication was infection (46%). The targeted leads included 2879 pacemaker leads (74.8%), 949 implantable cardioverter-defibrillator leads (24.6%), and 21 leads for which details were unknown; 46.6% of leads were passive fixation leads. The median lead dwell time was 74 months [interquartile range (IQR) 41-112]. Clinical success was obtained in 97.0% of procedures, and complete extraction was achieved for 96.5% of leads. Major complications occurred in 22/2205 procedures (1%), with a peri-operative or procedure-related mortality rate of 4/2205 (0.18%). Minor complications occurred in 3.1% of procedures. A total of 1552 leads (in 992 patients) with a median dwell time of 106 months (IQR 66-145) were extracted using the Evolution rotational TLE tool. In this subgroup, complete success was obtained for 95.2% of leads with a procedural mortality rate of 0.4%.

CONCLUSION

Patient outcomes in the PROMET study compare favourably with other large TLE trials, underlining the capability of rotational TLE tools and techniques to match laser methods in efficacy and surpass them in safety.

[Cardiology]

In 2020, new guidelines have been published by the European Society of Cardiology including those on non-ST-segment elevation acute coronary syndromes, atrial fibrillation and adult congenital heart disease. Regarding interventional cardiology, POPular TAVI opens the possibility of anti-platelet monotherapy after transcutaneous aortic valve replacement. EMPEROR-Reduced confirms the importance of SGLT2 inhibitors in the treatment of heart failure with reduced ejection fraction. Within the field of imaging, stress MRI has now become the first-line technique for the screening of coronary artery disease, demonstrating an excellent cost-benefit ratio. Finally, renin-angiotensin-aldosterone inhibitors do not appear to increase the risk of an infection by COVID-19.

Causes of recurrences after stereotactic radio-ablation for refractory ventricular tachycardia

Introduction

Stereotactic radio-ablation (STAR) has been recently introduced for the management of ventricular tachycardia (VT) refractory to antiarrhythmic drugs (AADs) and catheter ablation (CA). The incidence and mechanisms of VT recurrences after STAR remain unknown. We report causes of recurrence in patients (pts) after STAR.

Methods

From 09.2017 to 01.2020, 12pts suffering from refractory VT were enrolled. The underlying cardiopathy was ischemic in 3, inflammatory in 3 and idiopathic in 6 pts. Before STAR, an invasive electro-anatomical mapping (Carto3) of the VT substrate (VT-sub) was performed. A mean dose of 22±2Gy was delivered to the VT-sub using the Cyberknife® system.

Results

The ablation volume was 24±7cc and involved the interventricular septum (IVS) in 10. After a median follow-up of 9±7 months, VT burden decreased by 78% (mean value, from 89 to 20 VT/semester). Out of the 12 pts, 9 (75%) presented some form of VT recurrence (table): 1) that spontaneously resolved in 2 pts; 2) remote from the VT-sub in 2 cases; 3) managed with AADs that had failed before STAR in 2 cases; 4) within the treated VT-sub in 3 cases. In the latter 3 cases, one recurrence came from a site adjacent to the circumflex artery (mean dosis 14.4 Gy), and two were located within the treated IVS (one displaying marked fibrosis, and one with sarcoidosis). Only 4/12 (33%) pts required additional CA.

Conclusion

STAR led in our patients to a strong VT burden reduction. Recurrences occurred at sites remote from the irradiated volume, within the IVS or in under-dosed sites adjacent to critical structures.

Funding Acknowledgement

Type of funding source: None

Use of the wearable cardioverter-defibrillator - the Swiss experience

INTRODUCTION

Sudden cardiac death caused by malignant arrhythmia can be prevented by the use of defibrillators. Although the wearable cardioverter defibrillator (WCD) can prevent such an event, its role in clinical practice is ill defined. We investigated the use of the WCD in Switzerland with emphasis on prescription rate, therapy adherence and treatment rate.

MATERIALS AND METHODS

The Swiss WCD Registry is a retrospective observational registry including patients using a WCD. Patients were included from the first WCD use in Switzerland until February 2018. Baseline characteristics and data on WCD usage were examined for the total study population, and separately for each hospital.

RESULTS

From 1 December 2011 to 18 February 2018, a total of 456 patients (67.1% of all WCDs prescribed in Switzerland and 81.1% of all prescribed in the participating hospitals) were included in the registry. Up to 2017 there was a yearly increase in the number of prescribed WCDs to a maximum of 271 prescriptions per year. The mean age of patients was 57 years (&plusmn; 14), 81 (17.8%) were female and mean left ventricular ejection fraction (EF) was 32% (&plusmn; 13). The most common indications for WCD use were new-onset ischaemic cardiomyopathy (ICM) with EF &le;35% (206 patients, 45.2%), new-onset nonischaemic cardiomyopathy (NICM) with EF &le;35% (115 patients, 25.2%), unknown arrhythmic risk (83 patients, 18.2%), bridging to implantable cardioverter-defibrillator implantation or heart transplant (37 patients, 8.1%) and congenital/inherited heart disease (15 patients, 3.3%). Median wear duration was 58 days (interquartile range [IQR] 31&ndash;94) with a median average daily wear time of 22.6 hours (IQR 20&ndash;23.2). Seventeen appropriate therapies from the WCD were delivered in the whole population (treatment rate: 3.7%) to a total of 12 patients (2.6% of all patients). The most common underlying heart disease in patients with a treatment was ICM (13/17, 76.5%). There were no inappropriate treatments.

CONCLUSION

The use of WCDs has increased in Switzerland over the years for a variety of indications. There is high therapy adherence to the WCD, and a treatment rate comparable to previously published registry data. &nbsp.

Exclusively cephalic venous access for cardiac resynchronisation: A prospective multi-centre evaluation

BACKGROUND

Small series has shown that cardiac resynchronisation therapy (CRT) can be achieved in a majority of patients using exclusively cephalic venous access. We sought to determine whether this method is suitable for widespread use.

METHODS

A group of 19 operators including 11 trainees in three pacing centres attempted to use cephalic access alone for all CRT device implants over a period of 8 years. The access route for each lead, the procedure outcome, duration, and complications were collected prospectively. Data were also collected for 105 consecutive CRT device implants performed by experienced operators not using the exclusively cephalic method.

RESULTS

A new implantation of a CRT device using exclusively cephalic venous access was attempted in 1091 patients (73.6% male, aged 73 ± 12 years). Implantation was achieved using cephalic venous access alone in 801 cases (73.4%) and using a combination of cephalic and other access in a further 180 (16.5%). Cephalic access was used for 2468 of 3132 leads implanted (78.8%). Compared to a non-cephalic reference group, complications occurred less frequently (69/1091 vs 12/105; P = .0468), and there were no pneumothoraces with cephalic implants. Procedure and fluoroscopy duration were shorter (procedure duration 118 ± 45 vs 144 ± 39 minutes, P < .0001; fluoroscopy duration 15.7 ± 12.9 vs 22.8 ± 12.2 minutes, P < .0001).

CONCLUSIONS

CRT devices can be implanted using cephalic access alone in a substantial majority of cases. This approach is safe and efficient.

[Sinus node dysfunction, Brugada syndrome and long QT syndrome affecting the same patient : when genetics can't make head or tail of it]

The gene SCN5A encodes the cardiac sodium channel which, through the conduction of Na+ current into the cell, generates the fast upstroke of the action potential of cardiomyocytes. Pathogenic variants of SCN5A have been causally associated to several hereditary cardiac diseases including, among others, Brugada syndrome, congenital long QT syndrome and sinus node dysfunction. Recently, overlap syndromes have been described that are characterized by the simultaneous expression of mixed clinical phenotypes among two or more hereditary cardiac diseases associated to the gene SCN5A (HCD-SCN5A). For this reason, it is time to rethink about HCD-SCN5A as different expressions of the same complex spectrum encompassing multiple clinical phenotypes with pronounced overlaps instead of as distinct clinical entities.

[Cardiology]

In 2019, the guidelines on the new entity « chronic coronary syndrome » have been published. They influence importantly the work-up and treatment of patients with stable coronary artery disease. We will also report on publications showing the benefit of percutaneous aortic valve implantation (TAVI) in patients with aortic stenosis and low risk surgical risk. With regard to infectious endocarditis, we elucidate the importance of the vegetation's size for predicting mortality and the prognostic value of the positron emission tomography in predicting septic embolism. We highlight the spectacular results of the DAPA-HF study in patients with heart failure and review publications showing the important role of the detection of myocardial fibrosis and scar by cardiac MRI for risk stratification of sudden cardiac death.

Oesophageal perforation: an unexpected complication during extraction of a pacing lead. A case report

Background

Peri-procedural transoesophageal echocardiography (TOE) is important in monitoring and minimizing major complications during pacing lead extraction. It is a widely accepted precautionary measure, especially in extractions considered to be higher risk. Pacing lead extraction may be challenging, and it is associated with significant risk of major bleeding from vascular trauma.

Case summary

We present a case of an 87-year-old woman who had an extraction of a ventricular pacing lead that had perforated to an extra-cardiac location, most likely to the left pleural space. Peri-procedural TOE was used as a precaution. The entire pacing lead was successfully extracted with gentle traction using standard equipment (mechanical technique). Extraction was followed by development of pneumomediastinum and a left pleural effusion, initially attributed to pulmonary injury from the pacing lead but which proved to be related to oesophageal injury from the TOE.

Discussion

Transoesophageal echocardiography-related complications are uncommon but should be considered in cases of unexpected post-procedural deterioration. Clinical deterioration after a seemingly uneventful procedure should prompt a thorough case review. A systematic approach should be applied to identify the offending cause and enable corrective measures to be undertaken. This case report is an important reminder to all operators utilizing TOE for peri-procedural purposes that this precautionary measure itself also independently exposes the patient to additional risk.

Thrombo-embolic events in left ventricular endocardial pacing: long-term outcomes from a multicentre UK registry

Aims

Endocardial left ventricular (LV) pacing is a viable alternative in patients with failed coronary sinus (CS) lead implantation. However, long-term thrombo-embolic risk remains unknown. Much of the data have come from a small number of centres. We examined the safety and efficacy of endocardial LV pacing to determine the long-term thrombo-embolic risk.

Methods and results

Registries from four UK centres were combined to include 68 patients with endocardial leads with a mean follow-up of 20 months. These were compared to a matched 1:2 control group with conventional CS leads. Medical records were reviewed, and patients contacted for follow-up. Ischaemic stroke occurred in four patients (6%) in the endocardial arm providing an annual event rate (AER) of 3.6% over a 20 month follow-up; compared to 9 patients (6.6%) amongst controls with an AER of 3.4% over a 23-month follow-up. Regression analyses showed a significant association between sub-therapeutic international normalized ratio and stroke (P = 0.0001) in the endocardial arm. There was no association between lead material and mode of delivery (transatrial/transventricular) and stroke. Mortality rate was 12 and 15 per 100 patient years in the endocardial and control arm respectively with end-stage heart failure being the commonest cause.

Conclusion

Endocardial LV lead in heart failure patients has a good success rate at 1.6 year follow-up. However, it is associated with a thrombo-embolic risk (which is not different from conventional CS leads) attributable to sub-therapeutic anticoagulation. Randomized control trials and studies on non-vitamin K antagonist oral anticoagulants are required to ascertain the potential of widespread clinical application of this therapeutic modality.

Ventricular fibrillation treated by cryotherapy to the right ventricular outflow tract: a case report

BACKGROUND

Arrhythmias originating from the right ventricular outflow tract are generally considered benign but cases of cardiac arrest have been described, usually associated with polymorphic ventricular tachycardia or extrasystoles with short coupling intervals.

CASE PRESENTATION

We report the case of a 54-year-old Caucasian woman with symptomatic right ventricular outflow tract arrhythmias without structural heart disease who suffered a ventricular fibrillation arrest without prior malignant clinical features. Cryoablation was performed and an implantable cardioverter defibrillator was implanted. She has since been free of arrhythmia for 7 years and has asked that the implantable cardioverter defibrillator not be replaced when the battery becomes depleted.

CONCLUSIONS

Although usually benign, right ventricular outflow tract tachycardia can be life-threatening. Even the most malignant cases can be cured by ablation.

The Hot and the Cold: Radiofrequency Versus Cryoballoon Ablation for Atrial Fibrillation

Catheter ablation is superior to antiarrhythmic drugs in maintaining sinus rhythm for patients with atrial fibrillation (AF). Pulmonary vein (PV) isolation is the cornerstone of any AF ablation procedure. Conventionally, this is achieved by performing point by point lesions using radiofrequency (RF) energy. However, this is technically challenging, time consuming and is associated with a number of complications. Long-term durability of PV isolation is also a concern. To address these issues, 'one-shot' energy delivery systems and alternative energy sources have been developed. The cryoballoon system has emerged as the most commonly used alternative to point by point RF technology. In this paper, we compare the technology, biophysics and clinical data of cryoballoon to conventional RF ablation for AF. The safety and efficacy of cryoballoon compared to RF ablation is critically reviewed. We conclude by looking at future applications of this technology.

Femoral implantation and pull through as an adjunct to traditional methods in cardiac resynchronization therapy

BACKGROUND

We have described the use of femoral access followed by pull through of the lead to a pectoral position to circumvent difficulty in implanting a left ventricular (LV) lead by standard methods.

OBJECTIVE

The purpose of this study was to establish the effect of femoral implantation and pull through on the overall rate of success in percutaneous implantation of LV leads.

METHODS

We collected data prospectively in all attempts at LV lead implantation from the time that we envisioned the femoral pull-through approach.

RESULTS

In the 6 years to September 30, 2014, our group attempted to implant a new LV lead in 736 patients, including 16 who previously had failed attempts by other groups. A standard superior approach was successful in 726 of 731 patients (99.3%) in whom it was attempted. In 5 patients (0.7%), we failed to deliver a lead from a superior approach; in 5 of 16 patients, with previous failed attemtps (31%), we judged that those attempts had been exhaustive. In all 10 cases, LV lead placement was achieved from a femoral approach, with the procedure time being 186 ± 65 minutes. In the first case attempted, the pull through failed; the lead was tunneled to the pectoral generator. In 1 case, the coronary sinus was found to be occluded at the ostium: a transseptal approach was used with the subsequent pull through. No complication occurred. At 22.3 ± 18.5 months after the implantation, all systems implanted by a femoral approach continued to function.

CONCLUSION

Used as an adjunct to standard methods, the femoral access and pull through method allows percutaneous LV lead placement in virtually all cases.